+1 In Anesthesiology - Any Input?

[oh atoms]

I was hoping to learn a bit more about +1s in anesthesiology (and actually even hospitalist medicine) - from the little I know, it seems like these exist for training in more rural settings. Does the scope of practice and knowledge significantly differ from the 5 year route in anesthesiology (or IM for hospitalists?) And do family docs run clinics and then dabble in these areas on a pt basis, in which case is call routine? 

I don't know much about what the practical differences are between the +1 specialties and their counterparts; anyone have any input, or know of any resources that have more info? Thanks! 

[futureGP]

You would be in a town 10000-25000 a small hospital with 1-4 ORs.

 

Most cases are simple general/orthopaedic cases (hernia,chole). Dental cases, cataracts, colonoscopy etc. Epidural for labour.

 

Most people I've seen do part time 1-2 half days a week and mix it up with family med practice and some ER coverage.

 

You won't make money doing those cases because the billing codes aren't that great.

 

Most 5-yr anesthesia make money doing asa3-4 vascular cases/emergencies overnight and as +1, you won't do any of that.

 

 

Finding a job isn't hard, you just gotta find a community that has a surgeon wanting to do surgery, isn't lucrative enough for 5-year guys, and ORs open part time to full time doing bread and butter cases.

 

You don't need 5 years to learn anesthesia. 5 year guys just have more exposure to subspecialty anesthesia like pain, regional, cardiac, ICU, transplant etc and research.

[A-Stark]

You might not need 5 years to learn how to do simple inductions on healthy* outpatients, but cases are only straightforward until they're not. Royal College-trained anesthetists get a lot more medicine/ICU/cardiology exposure along with all those subspecialties, and it's not like learning a cardiac or neuro-induction is relevant only for a CABG or a crani. 

 

*healthy implying, I guess, ASA 1-2, but the trick is dealing with the unexpected - and having the diagnostic and management skills that are acquired in a 5 year residency in preparation for RCPSC exams. 

[katakari]

You have to do call. Frequency will depend on your call group. A +1 anesthetist I shadowed was 1 in 4. Money is good but nothing to write home about; you do it because you want a balance in your practice. ASA 1-2 cases only and the rare emergent ASA 3+ case (the patient will be sent to Hamilton, London etc. by default most of the time).

 

Seemed like a fun thing to do without having to be tied down to a hospital like an anesthetist or do the super stressful procedures. 

[oh atoms]

Thanks so much everyone, this was really helpful!  

[Tacrolimus]

Agreed with above, especially on the management of unexpected outcomes. Most PGY-2 residents can handle a ASA 1-2 case with minimal supervision, and I assume that is the level of training that the 2+1 program allows. Thinking about it, that's a quite limited patient population. I think if anesthesia is something you want to do regularly, then 2+1 is not enough at all unlike emergency medicine or hospitalist role in a surgical ward. Employability in anything that is called a city is likely very, very low. 

 

As for hospitalists, I don't know what their billing codes are and how they differ from IM, but from what I've seen (working at a community hospital), it feels somewhat IM-like, but in surgical wards where the surgeon doesn't want to be bothered by 12 on a chemstrip, or dosing adjustment for someone with a CrCl of 45 or adjusting coumadin to get to target INR. Correct me if that's a wrong assumption. 

[katakari]

Agreed with above, especially on the management of unexpected outcomes. Most PGY-2 residents can handle a ASA 1-2 case with minimal supervision, and I assume that is the level of training that the 2+1 program allows. Thinking about it, that's a quite limited patient population. I think if anesthesia is something you want to do regularly, then 2+1 is not enough at all unlike emergency medicine or hospitalist role in a surgical ward. Employability in anything that is called a city is likely very, very low. 

 

As for hospitalists, I don't know what their billing codes are and how they differ from IM, but from what I've seen (working at a community hospital), it feels somewhat IM-like, but in surgical wards where the surgeon doesn't want to be bothered by 12 on a chemstrip, or dosing adjustment for someone with a CrCl of 45 or adjusting coumadin to get to target INR. Correct me if that's a wrong assumption. 

 

Disagree.

 

http://anesthesiaweb.org/images/risk/Wolters-1996.pdf

The only study I could find on a brief look, but here 60% of all patients at a university hospital in a city of 1 million people are ASA 1-2.

 

2+1 would be working with no supervision.

 

I can drive 30 minutes from Hamilton in any direction and find a city with a hospital primarily staffed by 2+1s (Grimsby and Woodstock confirmed, Halton region or so I've heard, presumably also in cities surrounding Waterloo). Jobs exist for anyone who is willing to consider the rare and hard to find cities that names don't rhyme with -oronto.

 

Hospitalists are responsible for their own patients, much like IM, I'm sure they can be called for medical reasons to attend to other wards' patients, but that is not their sole responsibility.

[oshaku]

Disagree.

 

http://anesthesiaweb.org/images/risk/Wolters-1996.pdf

The only study I could find on a brief look, but here 60% of all patients at a university hospital in a city of 1 million people are ASA 1-2.

 

2+1 would be working with no supervision.

 

I can drive 30 minutes from Hamilton in any direction and find a city with a hospital primarily staffed by 2+1s (Grimsby and Woodstock confirmed, Halton region or so I've heard, presumably also in cities surrounding Waterloo). Jobs exist for anyone who is willing to consider the rare and hard to find cities that names don't rhyme with -oronto.

 

Hospitalists are responsible for their own patients, much like IM, I'm sure they can be called for medical reasons to attend to other wards' patients, but that is not their sole responsibility.

 

You mean to tell me Canada has more than 2 cities? Blasphemy!

What's next? Are you're gonna suggest there's more than 1 official language here too??

[A-Stark]

Disagree.

 

http://anesthesiaweb.org/images/risk/Wolters-1996.pdf

The only study I could find on a brief look, but here 60% of all patients at a university hospital in a city of 1 million people are ASA 1-2.

 

2+1 would be working with no supervision.

 

 

Some days you'll have a planned list of outpatient lap choles... that turns into an emergency trach and later an emergency laparotomy that needs intermittent epi and vaso boluses. Even a peds dental list doesn't necessarily stay straightforward (*ahem* childhood obesity +/- behavioural issues). 

[katakari]

Some days you'll have a planned list of outpatient lap choles... that turns into an emergency trach and later an emergency laparotomy that needs intermittent epi and vaso boluses. Even a peds dental list doesn't necessarily stay straightforward (*ahem* childhood obesity +/- behavioural issues). 

 

I completely agree there is superiority in a 5 year training and it would specifically prepare you for high risk cases handled at tertiary centers in addition to mastery of basic cases. I will take your word on the incidence of emergent trach in ASA 2 patients. I feel like if people were dying from FP anesthetists who are unable to handle these common deviations from standard procedure that no one would hire them and that their training would not be legitimized. 

[medafter30]

Was wondering if you guys have an idea about hospitalist (FM + 1 hospital medicine) with regards to job and lifestyle? 

 

Thanks 

[criselda]

At our hospital here in BC (urban/suburban, large community hospital) - hospitalists cover the vast majority of medical adult inpatients as many specialties act as consultants and do not admit. It is shift work, they come in at 7 am, round on around 12-15 patients and do 1-2 admits (there is some type of quota they fulfill), and most go home by 2 or 3 pm but must be available by phone until 5 pm. There are evening and overnight call shifts where one or two physicians cover the whole hospital for all sorts of things from Maalox to tanking patients. I was really blown away by what volume and acuity they are managing in our hospital...

 

I think there is flexibility as to how many shifts they work per week/month. Some do just hospitalist, some also have their own GP practice, others do walk in clinics on the side.

[medafter30]

Thanks  

[CharmingHedgehog]

Having worked with GP anesthesiologists, I think at some point (e.g. 5-7 years) the amount of experience and initiative for self-directed learning will be able to compensate for a lot of the missing years in terms of common crisis management. I don't think GP+1s would be expected to handle really bad cases, or overly complex, which is essentially the point of the 5 year program. However, thinking about all the decent sized non-academic centres that are staffed with GP+1s, and all the GP anaesthetists I've worked with, I can certainly say they are capable of handling more than ASA 1&2 patients. It wouldn't be uncommon for ASA 3 patients to go to a hospital like Sault Ste. Marie, where most anaesthetists graduated from the +1 program. Granted, things like cardiac rooms exist in non-academic centres, and they are definitely staffed by a Royal College trained anesthetist. But I'd say those count as complex surgeries and complex patients =D

[A-Stark]

Sorry, it's not an issue of "complexity". It's not altogether hard to learn how to do a cardiac induction. It's about the experience and training. And the exams. Sure, there are still some GP-surgeons around doing hernias or (maybe) appes, but it's about those times when the routine becomes the disaster.